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W. G. FEGAN

Compression sclerotherapy is a form of injection treatment for varicose veins that is being practiced in Dublin for over 20 years. The reasons for its development were, firstly, dissatisfaction with the usual forms of injection treatment because of the frequent incidence of widespread thrombophlebitis and because of the high recurrence rate and, secondly, dissatisfaction with surgery because of the inconvenience of hospitalization and the impossibility of treating large numbers of patients.

The technique is based on the fact that in almost all cases of symptomatic varicose veins, incompetent perforating veins are present, permitting the flow of blood from deep to superficial veins. This causes a secondary and reversible dilatation of the superficial veins as well as incompetence of the superficial vein. The object of compression sclerotherapy is to permanently occlude these incompetent perforating veins. This is achieved by injecting small amounts of sclerosant, using an empty vein technique, at the points of junction of the perforating and superficial veins.

In our diagnostic routine the patient is examined in the erect position and the varicose complexes are marked out by inspection, palpation and percussion. The patient then lies down and the leg is elevated, the heel resting on the surgeon's shoulder. In this position the superficial veins are empty and the muscles relaxed. The surgeon rapidly palpates the legs with his finger-tips. It is now possible, after a little practice, to determine the sites of the orifices in the fascia which transmit the perforating veins. These sites are marked and the doctor places his finger over them and asks the patient to stand up. Retrograde filling into the superficial veins is controlled by this method. The doctor then removes his fingers one by one from the orifices. If blood regurgitates into the superficial veins this suggests that an incompetent perforating vein is present at this point. These sites are carefully marked because these are the sites for injection. It is important to confirm the presence of incompetent perforating veins by noting retrograde filling in this way because thinning of the fascia due to varix and even fascial orifices transmitting normal perforating veins may be detected while examining the leg in the elevated position, and these should not be injected. When all the sites have been marked the patient lies down. There may be more than one incompetent perforating vein but there are rarely more than five in one leg. Injection is made using an all glass 2 ml. syringe, with a fine short narrow bore needle. This is easily done when the patient's legs are horizontal. There is no need to use a tourniquet. When the needle is in the vein the patient's leg is elevated. Firm digital pressure is put on the vein at either side of the injection point to ensure that the segment of vein injected is small and, therefore, no good valves destroyed. ½ -1 ml. syringe of sodium tetradecyl is injected slowly into the vein at this point.

Bandaging, which is the most important part of the treatment, follows injection. A firm 3" wide crepe bandage is used, the surgeon applying the bandage with the right hand while palpating the leg with the left hand to ensure even tension of the bandage. Immediately over the site of injection a sorbo rubber pad is bandaged in place. As many incompetent perforating veins as possible are injected at the first visit, this yielding the best results. Further injections may be given at subsequent visits. The whole leg is firmly bandaged and elastoplast applied over the bandages to hold them in place. It is most important to bandage a sorbo rubber pad into place over the course of the long saphenous vein at the rubber edge of the bandages to prevent the sharp edge of the bandages traumatizing the long saphenous vein and causing ascending thrombophlebitis. An elastic stocking is worn over the bandaged leg day and night until the patient comes for the next visit. Compression is of the utmost importance as it limits the sclerosant to the injected site and also prevents the development of a large thrombus which is more easily recanalized.

Walking is the patients important contribution to the treatment. The patient must walk immediately for at least an hour and must walk three miles a day until treatment is completed. The patient must avoid standing still at all times.

Compression must be maintained for six weeks after the last injection.

The only contra-indication to compression sclerotherapy is inability to walk or allergy to sodium tetradecyl sulphate. A large number of our cases have been pregnant women who have been treated with success. Over-weight patients are put on a weight-reducing diet because a better result is achieved in patients who have not got obese legs, because better compression can be maintained on the injection sites.

This method of treatment is also suitable for patients with varicose ulcers. The ulcer is dressed with a bland ointment, such as vaseline and the treatment continues as in patients without ulcers. If the ulcer is heavily infected an antibiotic is given systematically for five days. Many of these patients, in fact, suffer from the post phlebitic limb syndrome and healing is improved by dispersing the oedema in the leg by using a heavy elastic bandage during the day.

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